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Equipment Inventory
Office Info
Type of Office
Please Select
General Dentist
Oral Surgeon
Orthodontist
Pediatric Dentist
Periodontist
Office Name
Current Customer or Prospect
Please Select
AIDA
Prime Plus
No Current Plan
Not a current customer
How far out is hygiene booked?
Please Select
Less than 6 weeks
Less than 3 months
3-6 months
6-12 months
Management Software
Lease Renewal
Please Select
0-5 Months
6-12 months
1-2 years
3-4 years
5 years or over
Relocation / Expansion Plan in the next 5 years?
Please Select
Yes
No
Maybe
Hygienist or Associate Addition?
Hygienist
Associate
No
Operatories
Doctor Working Operatories
Unequipped Doctor Operatories
Hygiene Operatories
Unequipped Hygiene Operatories
Brand of Core Equipment
Room for Future Expansion?
Please Select
Yes
No
Does the office have aging equipment?
Please Select
Yes
No
Handpieces
Electrics
Please Select
Yes
No
Electric Brand
# of Electrics
High Speed Brand
Low Speed Brand
# of high speeds
# of low speeds
Imaging
Imaging Software
Panoramic Imaging
Please Select
None
2D - Film
2D - Digital
3D
Brand of Panoramic Imaging
Handheld X-Ray
Please Select
Yes
No
Intraoral Imaging
Please Select
Film
Phosphoric Plate
Sensor
Brand of Intraoral Imaging
CADCAM
Intraoral Scanner
Please Select
Yes
No
Brand of Intraoral Scanner
Milling Unit
Please Select
Yes
No
Brand of Milling Unit
Desire to Mill in Future?
Please Select
Yes
No
3D Printer?
Please Select
Yes
No
Brand of 3D Printer
Desire to 3D Print in future?
Please Select
Yes
No
Sterilization
Handpiece Maintenance System
Please Select
Yes
No
Brand of Handpiece Maintenance System
Cabinetry Condition?
Please Select
Looks Brand New
A Bit Used, but Clean
Looks dated
Autoclaves
Please Select
1
2
3
4
Brand of Autoclave
Statim
Please Select
Yes
No
Never wants one
Mechanical Room
Condition of Air Compressor
Please Select
Brand New
Good
Stable
Needs Replacing
Condition of Vacuum Pump
Please Select
Brand New
Good
Stable
Needs Replacing
Amalgam Separator
Please Select
Yes
No
Not needed
Email
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